CNMC Asthma Action Plan UPOEnglish).pdfAsthma Action Plan The goal of asthma treatment is to live a healthy, active life. Name Date of Birth Effective Dates ... Please complete and

Asthma Action PlanThe goal of asthma treatment is to live a healthy, active life.

Name Date of Birth Effective Dates/ / to / /

Health Care Provider Provider’s Phone

Parent/Guardian Parent’s Phone School

Additional Emergency Contact Contact Phone

GREEN means Go!Use CONTROL medicine daily

YELLOW means Caution!Add RESCUE medicine

RED means DANGER!Get help from a doctor now!

Asthma Severity Classification Asthma Triggers (Things that make your asthma worse) Flu Shot?

■■ Mild Intermittent ■■ Moderate Persistent■■ Mild Persistent ■■ Severe Persistent

■■ Colds ■■ Smoke ■■ Exercise ■■ Pollen ■■ Dust ■■ Animals:_________■■ Strong odors ■■ Mold/moisture ■■ Pests (rodents, cockroaches)■■ Season (circle): Fall, Winter, Spring, Summer ■■ Other:______________

■■ Yes■■ No

Green Zone: Go! – Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALL of these:

• Breathing is easy

• No cough or wheeze

• Can work and play

• Can sleep all night

Peak flow in this area:_________ to_________

(More than 80% of Personal Best)

Personal best peak flow:____________

■■ No control medicines required.■■ _____________________________________________, take______ puff(s) _____ times a day

Inhaled corticosteroid or inhaled corticosteroid/long-acting β−agonist

■■ ___________________________________________, take_____ by mouth once daily at bedtimeLeukotriene modifier

■■ Other_________________________________________________________________________________For asthma with exercise, ADD:■■ _____________________, _______ puffs with spacer 15 minutes before exercise

Fast-acting inhaled β−agonist

For nasal/environmental allergy, ADD:■■ __________________________________, use_______ spray(s) per nostril_______ times a day

Nasal corticosteroid

Yellow Zone: Caution! – Continue CONTROL Medicines and ADD RESCUE MedicinesYou have ANY of these:

• First sign of a cold

• Cough or mild wheeze

• Tight chest

• Problems sleeping,working, or playing


(50%-79% of Personal Best)

You have ANY of these:• Can’t talk, eat, or walk well• Medicine is not helping• Breathing hard and fast• Blue lips and fingernails• Tired or lethargic• Ribs show


(Less than 50% of Personal Best)

■■ ____________________, ______ puff(s) with spacer every ____ hours as neededFast-acting inhaled β−agonist

■■ ____________________, ______ nebulizer treatment(s) every ______ hours as neededFast-acting inhaled β−agonist

■■ Other__________________________________________________________________

ALWAYS use a spacer with your inhaler!

Call your DOCTOR if you have these signs often, use rescue medicinesmore than two times a week, or your rescue medicine doesn’t work!

■■ ______________________, ____ puffs with spacer every 15 minutes, for THREE treatmentsFast-acting inhaled β−agonist

■■ ___________________, ____ nebulizer treatment every 15 minutes, for THREE treatmentsFast-acting inhaled β−agonist

Call your doctor while administering the treatments.■■ Other_________________________________________________________________________________

IF YOU CANNOT CONTACT YOUR DOCTOR:Call 911 for an ambulance,

or go directly to the Emergency Department!

Red Zone: DANGER! – Continue CONTROL & RESCUE Medicines and GET HELP!

Approved by DC Department of Health

Adapted from NHLBI byChildren’s National Medical Center, 2006

This publication was supported in partby a grant from the DC Department of

Health, Asthma Control Program,with funds provided by

the Cooperative Agreement NumberU59/CUU324208-03 from the Centers

for Disease Control and Prevention(CDC). Its contents are solely the

responsibility of the authors and do notnecessarily represent the official views of

the CDC.

Permission to Reproduce Blank FormPatient or Parent/Guardian Signature Date

Health Care Provider Signature Date

Follow-Up Asthma Visit:_______________________________________________________________

SCHOOL MEDICATION CONSENT AND PROVIDER ORDER FOR CHILDREN AND YOUTH:Possible side effects of rescue medicines (e.g., albuterol) include tachycardia, tremor, and nervousness.■■ This student is capable and approved to self-administer the medicine(s) named above.■■ This student is not approved to self-medicate.■■ This student may be administered RESCUE medicine(s) (e.g., albuterol) by a school nurse or trained staff

as directed above.■■ As the parent/guardian, I understand that the school, its employees and its agents shall incur no liability

and shall be held harmless against any claims that may arise relating to the administration, supervision,training, or self-administration of medication. Form available at

www.dcasthma.orgwww.doh.dc.govwww.k12.dc.us

For more information,call (202) 442-5925

Government of theDistrict of ColumbiaAdrian M. Fenty, Mayor

PATIENT COPY

DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH SCHOOL HEALTH PROGRAM

STUDENT HEALTH AUTHORIZATION FORMS

Name of Student: Date of Birth: School: Social Security #: Grade:

PART I: PARENT/GUARDIAN CONSENT FORM

Parent/Guardian: Please complete and sign this form.

I hereby request and authorize the school nurse/licensed practical nurse/certified DCPS personnel to administer prescribed medications as directed by the physician to my son/daughter.

Student’s Name

I have received and read a copy of the procedures for medication authorization and agree to assume responsibilities as required. This medication is a new or renewedprescription. If this is a new prescription, enter the date and time of first dose given at home.

Date: Time: A.M. P.M.

Name of Parent/Guardian: Date: Please Print

Signature of Parent/Guardian Relationship

Please take this form to the student’s physician for completion

PART II: PHYSICIAN’S MEDICATION AUTHORIZATION ORDER

Physician: Please complete and sign this medication authorization order. Please check one: Original Renewal Change Name of Student: Date of Birth: Diagnosis: Asthma Telephone #: Name of Medication: Dose: Time and circumstances of administration at school: Expected duration of administration: Can reaction be expected? Yes No If yes, please describe: Physician’s Name: Physician’s Address: Telephone Number: Physician’s Signature: Date:

School Nurse DCPS Qualified Staff DC Public Schools












■■ Yes■■ No



















• Tight chest









■■ Other__________________________________________________________________
















the CDC.










SCHOOL NURSE/CHILD CARE COPY












■■ Yes■■ No



















• Tight chest









■■ Other__________________________________________________________________
















the CDC.










MEDICAL RECORDS COPY

Stepwise Approach for Managing Children and Adults with Asthma (from NAEPP 2002 Guidelines Update)

SEVERITY CLASSIFICATION Symptoms Before Treatment or Adequate Control

Daytime Symptoms

Nighttime Symptoms

PEF or FEV1

PEF Variability

Children Younger than 5 Years of Age

Step 4: Severe Persistent

Continual Frequent

60% >30% (PEF is % of personal best peak flow; FEV1 is % Predicted)

High-dose inhaled corticosteroids AND

Long-acting inhaled beta2-agonists

◊ And, if needed, corticosteroid tablets or syrup long term (2 mg/kg/day, usual max 60 mg per day). (Attempt to wean to high-dose inhaled corticosteroids.)

◊ Refer to an asthma specialist

Step 3: Moderate Persistent

Daily >1 night per week

>60 to <80% >30%

Low-dose inhaled corticosteroids AND Long-acting inhaled beta2-agonists

OR Medium-dose inhaled corticosteroids

◊ Alternative: Low-dose inhaled corticosteroids and either leukotriene modifier or theophylline

If needed, particularly in patients with

recurring severe exacerbations:

Medium-dose inhaled corticosteroid AND


◊ Alternative: Medium-dose inhaled corticosteroid and either leukotriene modifier or theophylline

◊ Consider referral to an asthma specialist

Step 2: Mild Persistent

>2x per week but <1x daily

>2 nights per month

80% 20-30%

Low-dose inhaled corticosteroids (nebulizer or MDI with spacer & face mask)

◊ Alternatives: Cromolyn (nebulizer or MDI with holding chamber) OR leukotriene modifier

Step 1: Mild Intermittent

2 days per week

2 nights per month

80% < 20%

Adults and Children Older than 5 Years of Age

High-dose inhaled corticosteroids AND Long-acting inhaled beta2-agonists

◊ And, if needed, corticosteroid tablets or syrup long term (2 mg/kg/day, usual max 60 mg per day). (Attempt to wean to high-dose inhaled corticosteroids.)

◊ Refer to an asthma specialist

Low-to–medium dose inhaled corticosteroids AND


◊ Alternative: 1. Increase inhaled corticosteroids within

medium-dose range, OR 2. Low-to-medium dose inhaled

corticosteroids & either leukotriene modifier or theophylline

If needed, particularly in patients with recurring severe exacerbations:

Increase inhaled corticosteroids within medium-dose range AND

add long-acting inhaled beta2-agonists

◊ Alternative: Increase inhaled corticosteroids within medium-dose range & add either leukotriene modifier or theophylline

◊ Consider referral to an asthma specialist

Low-dose inhaled corticosteroids

◊ Alternatives: Cromolyn, leukotriene modifier, nedocromil, OR sustained-release theophylline to serum concentration of 5-15 microgm/mL

◊ No daily medications needed.

Medications Required to Maintain Long-Term Control (Preferred Treatments in Bold Print)

Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A short course of systemic corticosteroids is recommended for severe exacerbations.

Goals of Asthma Therapy: • Minimal or no day or night symptoms

• Minimal or no exacerbations

• No limitations on activities, school, or work

• Minimal or no adverse medication effects The Baylor Health System “Rules of Two®”:

Patients with these criteria have persistent asthma, and maintenance therapy is needed for optimal control.

>2 uses of rescue medication per week >2 episodes per month of awakening at night with asthma symptoms >2 rescue medication refills per year

(All rights reserved. Rules of Two® is a federally registered trademark of Baylor Health Care System.) The Stepwise Approach to the NAEPP Guidelines:

• Gain control as quickly as possible, using a short course of oral corticosteroids if needed.

• Review treatment plan every 1-6 months: — Step down to the least medication necessary to maintain control. — Consider stepping up for patients whose asthma is not well-controlled. Be sure to review medication techniques, compliance, and environmental control. Asthma Predictive Index for Young Children

Frequent wheezing before 3 years of age PLUS:

One Major Criteria OR Two Minor Criteria Parental Asthma Allergic rhinitis Eczema Eosinophilia > 4% Wheezing apart from URIs

Predictive value for wheezing in school years: • Positive index: 76% Positive Predictive Value • Negative index: >95% Negative Predictive Value

(Castro-Rodriguez et al. Am. J. Respir. Crit. Care Med., 2000) Adapte

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Medication Dosage Info Child Dose Adult Dose

Inhaled Corticosteroids

Beclomethasone (QVAR) HFA: 40, 80 mcg/inh

Low Daily Dose Medium Daily Dose High Daily Dose

Age 5-11 years

40-80 mcg bid 80-160 mcg bid >160 mcg bid

Age >12 years


Budesonide (Pulmicort) DPI 200 mcg/inh or Respules 0.25, 0.5 mg


Neb for patients < 6 years

200 mcg bid 0.5 mg neb qday or divided bid

200-400 mcg bid 1 mg neb qday or divided bid

>400 mcg bid 2 mg neb qday or divided bid

Age > 17 years

200 mcg bid 200-400 mcg bid 400-800 mcg bid

Flunisolide (Aerobid) MDI: 250 mcg/inh


Age 6-15 years

500 mcg bid

Age > 15 years

500 mcg bid 500-1000 mcg bid >1000 mcg bid

Fluticasone (Flovent) MDI: 44, 110, 220 mcg/inh


Age 4-11 years 44-88 mcg bid 88-220 mcg bid >220 mcg bid

Age > 12 years 44-132 mcg bid 132-330 mcg bid >330 mcg bid

Mometasone (Asmanex) MDI: 220 mcg/inh


Not recommended

under age 12

Age > 12 years

220 mcg q pm 440 mcg qpm or div bid 440 mcg bid

Triamcinolone (Azmacort) HFA: 100 mcg/inh


Age 6-12 years


Age > 12 years


Combined Medication Fluticasone/Salmeterol(Advair)

DPI 100, 250, or 500 mcg/50 mcg

Age 4-11 years

100/50 mcg bid

Age > 12 years

Low: 100/50 mcg bid Medium: 250/50 mcg bid High: 500/50 mcg bid

Leukotriene Modifiers

Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo)

4 mg granules 4, 5 mg chew tab 10 mg tab 10, 20 mg tab 600 mg tab

4 mg qhs (2-5 yrs) 5 mg qhs (6-14 yrs) 10 mg qhs (>14 yrs) 10 mg bid (5-11 yrs) Not recommended under age 12

10 mg qhs 20 mg bid (>12 yrs) 600 mg 4x daily (2400 mg/day)

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Documents

CNMC Asthma Action Plan UPOEnglish).pdfAsthma Action Plan The goal of asthma treatment is to live a healthy, active life. Name Date of Birth Effective Dates ... Please complete and